Post on 19-Jan-2016
Canadian Forces Health Services
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Physicians Assistants and Pharmacists: Working Together
Lieutenant Commander Joe Dagenais B.Eng BSP PharmD CD
Canadian Forces Health Services
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Learning Objectives
1. Describe the factors that lead to Pharmacist scope of practise changes in Canada.
2. Outline the various changes in Pharmacist scope of practise.
3. Describe the pharmacy principle of Pharmaceutical Care.
4. Identify practise areas/ issues where collaboration between Physician Assistants and Pharmacists may occur.
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Current Canadian Health Care System
Problems:1.Accessibility (disadvantaged populations)2.Care outside of business hours3.Wait times4.Non-optimized health promotion including patient involvement and self-management5.Appropriate use of health care providers and resources6.Chronic care management7.Mental health care8.Elderly and end-of-life care9.Questionable fiscal effectiveness and sustainability
Canadian Academy of Health Sciences, 2014
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Collaborative Care
• Multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, caregivers and communities to deliver the highest quality of care across settings. (WHO)– collaborative care models ensure (based on the needs of the patient):
• the right professional;
• the right setting; and
• at the right time. (CAHS 2014)
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Relationship: Models of Care and Scope of Practice
Canadian Academy of Health Sciences, 2014
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Barriers to Collaborative Practice
Canadian Academy of Health Sciences, 2014
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Without Clear SoP
• Role confusion, competition among various HCPs, workplace tension, lack of trust, decreased professional identity, under/ over utilization of HCPs.
• Difficult for employers to optimize existing HR and assemble appropriate skill mix due to unclear understanding of education and the translation of knowledge into actual practice.
Health Council of Canada, 2005
Understanding a Pharmacist’s SOP
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Ontario Pharmacy Act 1991 (2009)
Scope of Practice of pharmacy is:
a)the custody, compounding, dispensing and prescribing of drugs;
b)the provision of health care aids and devices;
c)the provision of information and education related to the use of anything mentioned in clauses (a) and (b); and
d)the promotion of health, prevention and treatment of disease, disorders and dysfunctions through monitoring and management of medication therapy.
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Pharmacist Controlled Act
1. Dispensing, selling or compounding a drug or supervising the part of a pharmacy where drugs are kept.
2. Administering, by injection or inhalation, a substance specified in the regulations.
3. Prescribing a drug specified in the regulations.
4. Performing a procedure on tissue below the dermis.
Ontario Regulation 302/12
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Pharmacist SOP By Province
Canadian Pharmacists Association
UNDERSTANDING HOW PHARMACISTS THINK
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Pharmacy Education• Anatomy, physiology, pathophysiology, pharmacology, medicinal
chemistry, toxicology, pharmacokinetics– CV, psychiatry, oncology, pain, endocrinology, neurology,
gastroenterology, bone/ joint, infectious disease, hematology, immunology/ transplant, dermatology, ENT…
• Patient assessment• Critical appraisal, communication, self-directed learning, group
processes• Healthcare systems• Nutrition• Laboratory analysis• Pharmacoepidemiology• Practical Experience (Hospital/ Community)
College of Pharmacy University of Alberta
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Pharmaceutical Care
“Pharmaceutical care is a patient-centered practice in which the practitioner assumes responsibility for a patient’s drug-related needs and is held accountable for this commitment”
-Requires: - the patient’s cooperation and coordination with the patient’s other
health care providers.
- rational decision-making process (Pharmacotherapy Workup)- Identify drug therapy problems (current or potential)- Develop care plan/ recommendations- Follow-up evaluation
Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.
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Drug Therapy Problem
“…are undesirable events or risks experienced by the patient that involve or are suspected to involve drug therapy and that inhibit or delay him/ her from achieving the desired goals of therapy.”
1.Unnecessary drug therapy
2.Needs additional drug therapy
3.Ineffective drug
4.Dosage too low
5.Dosage too high
6.Adverse drug reaction (drug/drug, drug/food, drug/test)
7.Non-adherence
Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.
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Pharmacotherapy Workup
Two questions:
1.Is the patient’s problem caused by drug therapy?
2.Can the patient’s problem be treated with drug therapy?
– Indication– Effectiveness– Safety– Adherence
Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.
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Pharmacotherapy Workup
Indication:
Indication Drug Product Dosage regimen Outcomes
Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.
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Pharmacotherapy Workup
Indication:
Indication Drug Product Dosage regimen Outcomes
Effectiveness
Safety
Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.
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Pharmcotherapy Workup
Effectiveness
Indication Drug Product Dosage regimen
Abnormal Lab Values
Signs & Symptoms
Labs
Effectiveness
Outcomes
Clinical
Goals of Therapy
Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.
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Pharmacotherapy Workup
Safety:
Indication Drug Product
Adverse Drug Reaction
Toxicity
Dosage regimen
Abnormal Lab Values
Signs & Symptoms
Labs
Effectiveness
Outcomes
Safety
Labs Clinical
Clinical
Goals of Therapy
Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.
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Pharmacotherapy Workup
Adherence:
“…someone who is not able or willing to take an appropriate, effective, and safe medication as intended”
The patient:
- does not understand instructions
- prefers not to take medication
- forgets
- too expensive
- cannot swallow or self-administer
Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.
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Drug Therapy Problem
1. Unnecessary drug therapy
2. Needs additional drug therapy
3. Ineffective drug
4. Dosage too low
5. Dosage too high
6. Adverse drug reaction
7. Non-adherence
Recommendations to other healthcare providers
Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide.
Indication
Adherence
Safety
Effectiveness
EXAMPLES OF WHERE WE CAN WORK TOGETHER
Hospital or Outpatient Practices
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Collaborative Practice Examples
• Medication reviews• Medication consults• Diabetes clinics• Travel medicine• Chronic Care• Adherence issues• Smoking cessation • Academic Detailing
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Medication Reviews/ Consults
• 65 yrs or older: >5 or more medications: – 13% private households– 53% healthcare institutions
• 87% of pharmacist recommendations accepted • Reviews:
– Present and past therapies• drug, dose, frequency, duration, efficacy/ side effects
– Patient’s expectations from drug therapy– Recommendations provided
• Deliverable: consult note
Health Reports, Vol. 20, no. 1, March 2009 • Statistics Canada
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Travel Medicine
• Collaborative practice– Physician– PA– NP– RN– Pharmacist
• Preventative medication– Immunizations– Anti-malaria medications– Information/ Education
• With/ without collaborative prescribing agreement
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Immunization nurse will contact you to book appointment.
Present for booked appointment with immunization nurse in office 4054 of Bldg S80 clinic (bring your immunization book). Necessary vaccines will be administered, and prescriptions (e.g. antimalarials) provided to present to pharmacy to be filled.
For personal travel, immunization nurse will provide you with traveler health advice
If necessary, book appointment with your doctor.
See CDU clerk: QL 6A Med Tech, PA or MO can confirm medical fitness for deployment.
For deployment, you will meet with PMED for:
• Mission specific brief • Force Health Protection Recommendations• Clothing dip if required
If you take chronic medications, ensure you obtain a prescription to bring to pharmacy to fill a deployment supply of your medications
Complete appropriate form for Personal Travel or Deployment Travel. Attach form in email to: +Travel Medicine@CF H Svcs C (A) Halifax
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Chronic Care
• Diabetes– A1C (-2.1% vs -0.9%, P = .03)
• HTN– SBP (-9.3 mm Hg)
• CV– LDL ~0.44 mmol/l reduction
• INR (physician vs pharmacist)- 71% vs 81% of visits- 65% vs 73% time in therapeutic range
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Diabetes Clinic
• Collaborative Practice:– Sponsoring physician– Nurse/ PA– Dietician– Pharmacist
• Certified Diabetes Educator
• Interpret lab tests
• Provide recommendations on initiating and altering DM drug therapy
• Advances in DM drug therapy
• With/ without collaborative prescribing agreement (delegated acts)
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Adherence
• Financial– Drug plan assistance– Cheaper drug or dose – De-prescribing– Dispensing fees
• Frequency• Formulation (taste, size)• Patient education
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Smoking Cessation
• Pharmacist: RR 0.77 compared to advice to quit • Behavioral counseling• Medication education/ Prescribing
– NRT– Bupropion– Varenicline
• Prescribing• Follow-up
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Conclusions
• Pharmacists are more than simply dispensers.
• Evidence shows our involvement in collaborative teams leads to improved patient care.
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Questions?
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References• Nelson S, Turnbull J, Bainbridge L, et al. (2014) Optimizing Scopes of Practice: New Models for a New Health
Care System. Canadian Academy of Health Sciences. Ottawa, Ontario. • Baranek PM. (2005) A Review of Scopes of Practice of Health Professions in Canada: A Balancing Act. Health
Council of Canada. Toronto. Ontario.• Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: the clinician’s guide. 2004• Maxwell-Alleyne A, Farber A. Pharmacists’ Expanded Scope of Practice: Professional obligations for physicians
and pharmacists working collaboratively. Ontario Medical Review. Apr 2013; 17-19.• Tannenbaum C, Tsuyuki T. The Expanding Scope of Pharmacists’ practice: implications for physicians. CMAJ
2013; • Young S, Bishop L, et al. Comparison of pharmacist managed anticoagulation with usual medical care in a family
medicine clinic. BMC Family Practice 2011, 12:88• Garton L, Crosby J. A retrospective assessment comparing pharmacist-managed anticoagulation clinic with
physician management using international normalized ratio stability. J Thromb Thrombolysis (2011) 32:426–430• Kennedy A, Chen H, et al. Improving Population Managemet through Pharmacist-Primary Care Integration: A Pilot
Study.• Carter B, Rogers M, et al. The potency of team-based care interventions for hypertention: A meta-analysis. Arch
Intern Med. 2009;169(19):1748-1755• Santschi V, Chiolero A, et al. Impact of Pharmacist Care in the Management of Cardiovascular Disease Risk
Factors.Arch Intern Med. 2011; 171(16):1441-1453.• Choe HM, Mitrovich S, et al. Proactive case management by a clinical pharmacist: a randomized controlled trial.
Am J Manag Care. 2005;11:253-260